Healthcare Provider Details

I. General information

NPI: 1528250800
Provider Name (Legal Business Name): LISA PENN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2007
Last Update Date: 08/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5344 FAIRTREE RD
BEDFORD HTS OH
44146-1522
US

IV. Provider business mailing address

5344 FAIRTREE RD
BEDFORD HTS OH
44146-1522
US

V. Phone/Fax

Practice location:
  • Phone: 440-439-9541
  • Fax:
Mailing address:
  • Phone: 440-439-9541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN103018
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: